Effect of socio-economic deprivation on refugee health: a natural experiment study in Germany

Abstract Background Characteristics of the place of residence have been proposed as a key determinant of physical and mental health, but so far, little experimental evidence exists. The quasi-random dispersal of refugees in Germany serves as a natural experiment to study the causal relationship between socio-economic deprivation and health as well as the impact of the social context on this relationship. Methods Refugees subject to dispersal policy (n = 1723) were selected from the nation-wide German IAB-SOEP-BAMF Panel from 2016 to 2018. The effect of German Index of Socioeconomic Deprivation quintiles (Q1-Q5) on change between baseline (t0) and follow-up (t1) in mental (mcs) and physical (pcs) health component scales of SF-12 were analysed using multi-level linear regression. Social context variables were included in a mediation analysis. Results Across quintiles, mental health improves (Δmcs=0.5) and physical health declines (Δpcs=-0.8) between t0 and t1. Fully adjusted models show a negative, dose-responsive relationship between deprivation and physical health, which is statistically significant for Q4 (coef. Q4vsQ1: -1.84, 95%CI: -3.50;-0.17). Models for mental health show an improvement in Q5 (coef. Q5vsQ1: 6.00, 95%CI: 1.70;10.31). Social context variables have no effect on physical health but slightly diminish the effect on mental health (coef. Q5vsQ1: 4.78, 95%CI: 0.65;8.90). Conclusions The quasi-random dispersal of refugees in Germany acts as a natural experiment to disentangle selection effects from the relationship between deprivation and health. Results suggest a negative effect of deprivation on physical health and a potential positive effect on mental health which can be partially explained by the social context. Limitations are the small sample sizes in deprived quintiles and short follow-up periods. This analysis can act as a magnifying glass for similar effects among other population groups, but causal paths need to be investigated further. Key messages The quasi-random dispersal of refugees in Germany acts as a natural experiment to disentangle selection effects from the relationship between deprivation and health. Results from a natural experiment suggest a negative effect of deprivation on physical health and a potential positive effect on mental health which can be partially explained by the social context.


Background:
There is a knowledge gap regarding the risk for labour market marginalisation among younger cohorts of refugees and nonrefugee immigrants. We investigated if the risk of long-term unemployment (LTU) and disability pension (DP) differs between young refugees and non-refuge immigrants compared to the Swedish-born. The role of age at arrival, duration of residency and morbidity in this association was also investigated.

Methods:
All 19-to 25-year-olds residing in Sweden on 31 December 2004 (1691 refugees who were unaccompanied by a parent at arrival, 24,697 accompanied refugees, 18,762 non-refugee immigrants and 621,455 Swedish-born individuals) were followed from 2005 to 2016 regarding LTU (>180 days annually) and DP using nationwide register data. Cox regression models were used to estimate crude and multivariate-adjusted (adjusted for several socio-demographic, labour market and health-related covariates) hazard ratios (aHRs) with 95% confidence intervals.

Results:
Compared to the Swedish-born, all migrant groups had around a 1.8-fold higher risk of LTU (range aHR = 1.71-1.83) and around a 30% lower risk of DP (range aHR = 0.66-0.76). Older age at arrival was associated with a higher risk of LTU only for non-refugee immigrants. Both older age at arrival and a shorter duration of residency were associated with a lower risk of DP for all migrant groups. Psychiatric morbidity had the strongest effect on subsequent DP, with no significant differences between migrant groups and the Swedish-born (range aHR = 5.1-6.1).

Conclusions:
Young immigrants had a higher risk of LTU and a lower risk of DP than their Swedish-born peers. No differences between the different immigrant groups were found. Age at arrival, psychiatric morbidity and duration of residency are strong determinants of being granted DP. Key messages: Young refugees and non-refugee immigrants both had a similar higher risk of long-term unemployment and a similar lower risk of disability pension than their Swedishborn peers. Age at arrival, psychiatric morbidity and duration of residency are strong determinants of being granted disability pension for young refugees and non-refugee immigrants in Sweden.

Background:
Characteristics of the place of residence have been proposed as a key determinant of physical and mental health, but so far, little experimental evidence exists. The quasi-random dispersal of refugees in Germany serves as a natural experiment to study the causal relationship between socio-economic deprivation and health as well as the impact of the social context on this relationship.

Methods:
Refugees subject to dispersal policy (n = 1723) were selected from the nation-wide German IAB-SOEP-BAMF Panel from 2016 to 2018. The effect of German Index of Socioeconomic Deprivation quintiles (Q1-Q5) on change between baseline (t0) and follow-up (t1) in mental (mcs) and physical (pcs) health component scales of SF-12 were analysed using multilevel linear regression. Social context variables were included in a mediation analysis.

Conclusions:
The quasi-random dispersal of refugees in Germany acts as a natural experiment to disentangle selection effects from the relationship between deprivation and health. Results suggest a negative effect of deprivation on physical health and a potential positive effect on mental health which can be partially explained by the social context. Limitations are the small sample sizes in deprived quintiles and short follow-up periods. This analysis can act as a magnifying glass for similar effects among other population groups, but causal paths need to be investigated further.

Key messages:
The quasi-random dispersal of refugees in Germany acts as a natural experiment to disentangle selection effects from the relationship between deprivation and health. Results from a natural experiment suggest a negative effect of deprivation on physical health and a potential positive effect on mental health which can be partially explained by the social context.